Type 2 diabetes: what's next after metformin?

With a range of blood glucose-lowering medicines on the market, it can be hard to decide what to prescribe for patients needing more than metformin. 


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 Medicines and type 2 diabetes

Type 2 diabetes: what's next after metformin?

Key points

  • Adherence is a critical issue to address with patients who are prescribed metformin.
  • Choice of second- and third-line medicines for addition to metformin should be individualised, guided by each patient's clinical considerations and each medicine's characteristics.
  • Usual second-line options are sodium-glucose linked transporter 2 (SGLT2) inhibitors, dipeptidyl peptidase 4 (DPP-4) inhibitors, sulfonylureas and glucagon-like peptide 1 (GLP-1) receptor agonists. 
  • Treatment algorithms reflect the complexity of treatment decisions but offer consistent guidance on a stepped/progressive approach to blood glucose control.

Quality improvement opportunities for patients with diabetes and CVD

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The relationship between diabetes and increased risk of mortality from cardiovascular disease (CVD) is well established. What opportunities still remain in general practice to identify at risk patients and optimise their management?

Read more


NPS RADAR Insulin glargine 100 IU/mL injections: PBS listing changes

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A new brand of insulin glargine has been listed to replace brands going off the market. Information for health professionals to support their patients with diabetes that may be affected by the changes.

Read the full article


Australian Prescriber: Second steps in managing type 2 diabetes

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Dr Carolyn Petersons
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Metformin is still first choice for type 2 diabetes, but what comes next? In the October 2018 issue of Australian Prescriber, Dr Carolyn J Petersons sorts out the second steps in managing type 2 diabetes.

Read the full article

Listen to the podcast.

Episode 36 – Dhineli Perera interviews Dr Carolyn Petersons about the second- and third-line drugs for type 2 diabetes. After metformin, what comes next?


Empagliflozin indications extended

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Empagliflozin is now TGA-approved for reducing cardiovascular deaths in patients with type 2 diabetes with established cardiovascular disease.

What is the evidence, and what does this mean in clinical practice?

Read the full article. 


NPS RADAR: Insulin glargine 300 IU/mL solution (Toujeo) for diabetes mellitus

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Insulin glargine 300 IU/mL (Gla-300) solution is another option for adults with type 1 or type 2 diabetes requiring a long-acting basal insulin. Gla-300 is a concentrated formulation of the PBS-listed Gla-100.

Read more about this long-acting insulin.


Metabolic syndrome and diabetes: how much blame does sugar deserve? 

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An increasing number of journal articles and media stories are highlighting the potential role of dietary sugar, and particularly added fructose, as a major contributor to ill health, from cardiovascular disease to type 2 diabetes to metabolic syndrome.

Find out more about the evidence for the role of sugar in these conditions.


CPD options

Consolidate your knowledge about type 2 diabetes, brush up on current guidelines and practices and earn CPD points through our learning activities.

For GPs:


Webinar: CV risk in patients with type 2 diabetes and CVD: Getting to the heart of diabetes

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Listen to our multidisciplinary panel of experts discuss the prevention of CV events in patients with both type 2 diabetes and CVD. Discussion covers:

  • Evidence-based strategies to reduce CV risk for patients with diabetes and CVD
  • Advice on how to individualise choice of blood glucose-lowering agents
  • The latest Australian blood glucose treatment algorithm for type 2 diabetes
  • An update on the latest CV outcome trial data and how this impacts your practice  

Listen to the webinar on demand

This program was funded by Boehringer Ingelheim Pty Limited and Eli Lilly Australia Pty Limited and managed through VentureWise, a wholly owned commercial subsidiary of NPS MedicineWise. The program has been designed, developed and implemented by NPS MedicineWise with complete independence and editorial control and is based on best practice guidelines.

  • Evidence-based strategies to reduce CV risk for patients with diabetes and CVD
  • Advice on how to individualise choice of blood glucose-lowering agents
  • The latest Australian blood glucose treatment algorithm for type 2 diabetes
  • An update on the latest CV outcome trial data and how this impacts your practice  

For your patients: Lifestyle and metformin decision aid

This decision aid is for people who have been diagnosed with type 2 diabetes, have tried lifestyle changes and are deciding whether to continue with lifestyle changes alone or start metformin. It can be used before a consultation to learn about the options, during the consultation to discuss and jointly decide on an option or at another time with discussion at a follow-up consultation.


Principles for pharmacological management of type 2 diabetes

Metformin is the usual first-choice medicine for people with type 2 diabetes and is used alongside lifestyle modifications such as changing diet and increasing physical activity.1-4 It is started either at diagnosis or after 2–3 months of lifestyle modifications depending on each patient’s clinical circumstances.1,3 Sulfonylureas may be used if metformin is contraindicated or cannot be tolerated.2

Guidelines recommend intensifying treatment if individualised HbA1c targets are not achieved.2 A second medicine is usually added if the patient’s target HbA1c levels have not been reached with a single medicine after 3 months of treatment.1-3

The choice of second- and third-line medicine should be individualised1,3 guided by: 

  • clinical considerations, such as presence or high risk of cardiovascular disease, heart failure, chronic kidney disease, hypoglycaemia
  • medicine adverse effect profile 
  • contraindications, and 
  • cost.2 

Other important considerations are PBS restrictions and patient preference.1

Usual second-line options are:

  • sodium-glucose linked transporter 2 (SGLT2) inhibitors
  • dipeptidyl peptidase 4 (DPP-4) inhibitors
  • sulfonylureas and 
  • glucagon-like peptide 1 (GLP-1) receptor agonists.2

Before adding a second or third blood glucose-lowering medicine, other comorbidities or concurrent medications affecting blood glucose control should be reviewed, as well as lifestyle factors and adherence to treatment.2,4

Insulin is not usually considered until doctor and patient are selecting a third-line medicine1-3 although some patients may need to add or change to insulin sooner.1,2


Evidence summary on type 2 diabetes

The prevalence of diabetes is increasing, with an estimated 6% of Australians currently diagnosed with the chronic disease.5

Diabetes impacts quality of life, life expectancy and morbidity as a result of microvascular complications (retinopathy, nephropathy and neuropathy) and the increased risk of macrovascular complications (ischaemic vascular disease, stroke and peripheral vascular disease).6

Good glycaemic control reduces the development or progression of diabetes complications and can improve quality of life.26

About 60% of people with type 2 diabetes have cardiovascular disease and around 65% of all cardiovascular disease deaths in Australia occur in people with diabetes.7

Addressing lifestyle factors, blood pressure and blood lipids are just as essential, as they seem even more effective than glycaemic control in reducing the risk of cardiovascular complications.8

Reducing risk of cardiovascular events in people with type 2 diabetes requires concurrent management of lifestyle factors, blood pressure, lipids and blood glucose.5